Pharmacology Section

DOI: 10.7860/JCDR/2016/16430.7047

Original Article

Antecedent Drug Exposure Aetiology and

Management Protocols in Steven-Johnson
Syndrome and Toxic Epidermal Necrolysis,
A Hospital Based Prospective Study

Samina Farhat1, Muddasir Banday2, Iffat Hassan3

ABSTRACT
Aim: The study sought to identify the magnitude and
characteristic of severe cutaneous adverse reactions (SCARs)
like StevenJohnson syndrome (SJS) and Toxic Epidermal
Necrolysis (TEN).
Materials and Methods: A prospective study was conducted
by the Department of Pharmacology in association with
Department of Dermatology in SMHS hospital. The study was
carried out from June 2013-June 2015 on hospitalized cases
of cutaneous adverse drug reaction reporting in hospital. The
SCARs were reported in a structured questionnaire based on
adverse drug reaction (ADR) reporting form provided by the
Central Drug Standard Control Organization (CDSCO) Ministry
of Health and Family welfare, Government of India. The SCARs
were analysed for their characteristics, causality, severity and
prognosis. Causality assessment was done by using a validated
ADR probability scale of Naranjo as well as WHO Uppsala
Monitoring Center (WHO-UMC) system for standardized case
causality assessment. The management protocol were analysed
for their clinical outcome through a proper follow up period.

Results: A total of 52 hospitalized cases of cutaneous adverse

drug reactions were reported during the study period. We
identified a total of 15 cases (28%) of SCARs involving
9(17%) of SJS and 6 (12%) of TEN. SJS was seen in 2(22%)
males and 7(78%) females. TEN was seen in all females
(100%) and in no male. Drugs implicated in causing these life
threatening reactions were identified as anticonvulsant agents
like carbamazepine (CBZ), phenytoin (PHT) and Lamotrigine
(LTG), oxicam NSAID, Sulfasalazine and levofloxacin. Despite
higher reported mortality rates in SJS and TEN all patients
survived with 2 patients surviving TEN suffered from long term
opthalmological sequelae of the disease.
Conclusion: Present study suggest that drug induced cutaneous
eruptions are common ranging from common nuisance rashes
to rare life threatening diseases like SJS and TEN, SJS/TEN
typically occur 1-3 weeks after initiation of therapy. Aromatic
AEDs, LTG, oxicam NSAIDs, sulfasalazine and levofloxacin
have a tremendous potential to trigger SCARSs. To ensure safe
use of pharmaceutical agents and better treatment outcomes
post marketing voluntary reporting of severe rare and unusual
reactions remains inevitable.

Keywords: Anticonvulsants, Oxicam NSAIDs, Severe cutaneous adverse reactions (SCARs)

Introduction
Adverse drug reactions (ADRs) are the inevitable consequence of
pharmacotherapy. Cutaneous manifestations are among the most
frequent adverse reaction to drugs [1]. Several multicentric trails
have established that acute cutaneous reaction to drugs affected
3% of hospital inpatients. Reactions usually occur a few days to
4 weeks after initiation of therapy [2]. SJS and TEN are two rare
acute life threatening SCARs characterized by mucocutaneous
tenderness, erythema, and extensive exfoliation and detachment of
epidermis. SJS is characterized by <10% of body surface area of
epidermal detachment, SJS-TEN overlap by 10-30% and TEN by
>30%. SJS and TEN have an annual incidence of 1.2-6 and 0.4-1.2
per million peoples respectively. Both effect women more frequently
than men with a ratio of 1.5:1 and the incidence increases with
age [3-6]. The average mortality rate is 1-5% for SJS and 25-35%
for TEN. Elderly, immunocomprised and those on radiotherapy are
at higher risk. Around 100 drugs have been identified as causal
agents of SJS/TEN [3,4,7-12]. Most frequently implicated drugs
are sulphonamides, antibiotics, oxicam NSAIDs, quinolones, AEDs
and allopurinol [13].
In view of the above facts a prospective study was undertaken with
an objective to estimate risk of SJS and TEN associated with use
of specific drugs in patients of North Indian ethnic background.
Journal of Clinical and Diagnostic Research. 2016 Jan, Vol-10(1): FC01-FC04

Moreover, since the treatment protocols are not well established

with clear- cut outcome the patients were therefore, followed up to
recognize the outcome and asses the development of complication
sequelae which could be delayed but debilitating.

MATERIALs AND METHODS

The study was carried out by the Department of Pharmacology
and Dermatology in SMHS, Government Medical College, Srinagar,
India. A prospective study was conducted between June 2013June 2015 which included patients who were admitted to the
hospital with a diagnosis of various patterns of cutaneous adverse
drug reaction (CADRs). These also included SJS/TEN patients as
an important group because of their rarity of occurrence. The study
received an approval from college ethical committee.
Data collection and drug enquiry: After obtaining informed
consent a structured questionnaire was used to interview the
patients clinically diagnosed as SJS/TEN with a definite antecedent
drug history. The questionnaire included the contents based on
suspected ADR reporting form provided by CDSCO, Ministry of
Health and Family Welfare, Government of India. It was used to
gather information on patients preceding hospitalization. The
drug history included brand/generic name of drug, manufacturer,
batch no, expiry date, timing of use, dose, indications, plasma
1

Samina Farhat et al., Antecedent Drug Exposure and Management in SJS and TEN

concentration of drug if available for low therapeutic range drugs,

previous exposure and previous ADR if any. For seriously ill patients
and children to be interviewed patient medical record and family
members provided the information. In addition clinical examination
and laboratory parameters were also recorded in questionnaire.
Causality assessment was performed using a Naranjo scored
algorithm [14]. This method incorporates ten questions or criteria
related to the ADR. Every question is provided with a particular score
based on the presence or absence of those criteria. These criteria
are: (i) Previous reports; (ii) Event after drug was administered; (iii)
Event abate on drug removal; (iv) Reaction appeared when the drug
was administered; (v) Other non-drug causes for the adverse event;
(vi) Was a toxic serum concentration noted; (vii) Reaction more
severe with increased dose or less severe with decreased dose;
(viii) Did the reaction appear when a placebo was given; (ix) Does
patient have a history of similar reaction with drug or drug class; (x)
ADR confirmed objectively.
Based on the scoring the probability that the adverse event was
caused by the drug was classified as definite (score 9), probable
(5-8), possible (1-4) or doubtful (0).
Moreover, a highly dependable WHO-UMC system [15] for case
causality assessment has also been applied to reinforce the reliability
of the study. The various causality categories based on assessment
criteria are certain, probable/likely, possible, unlikely conditioned/
unclassified and unassessable/unclassifiable. The rationale for
combining two tools is to overcome limitations associated with
individual methods. In our study all patients of SJS/TEN were
evaluated for severity and prognosis by using SCORTEN prognostic
scoring system [16,17] that has been developed to correlate mortality
with selected parameters [Table/Fig-1]. The management protocol
would involve prompt identification and withdrawal of culprit drug
(s) followed by vigorous supportive care. The drug therapy included
systemic steroids in form of i.v. Dexamethasone or Hydrocortisone
on short-term basis.

RESULTS
A total of 52 patients were identified as CADRs of which 15 cases
(28%) were SCARs of these 9 (17%) cases were diagnosed as SJS
and 6 (12%) cases as TEN. SJS was seen in 2 (22%) males and 7
(78%) females while as TEN was diagnosed in females only.
The study revealed that these events were associated more
commonly with short term therapy with agents like lamotrigine,
carbamazepine, valproic acid and phenytoin. The other drugs
associated were levofloxacin, oxicam NSAIDs and Ibuprofen. The
study revealed that almost all cases of SJS/TEN develop within
two months of use of aromatic anticonvulsant and within 3 week of
Prognostic factors

Points

Age >40 years

Presence of Malignancy/ Haematological

malignancy

Epidermal Detachment >30%

Heart rate >120/min

Bicarbonate < 20mmol/L

Urea > 10mmol/L

Glycaemia >14mmol/L
SCORTEN

1
Probability of death(%)

0-1

12

35

58

90

[Table/Fig-1]: SCORTEN: A Prognostic scoring system for patients with epidermal

necrolysis

www.jcdr.net

lamotrigine use. All the hospitalized patients of SJS/TEN survived

following discharge from the hospital.
Among patients of TEN, 2 patients continued to suffer from ocular
complications (like chronic inflammation, fibrosis entropion, trichiasis
and symblepheron) and persistent mucosal lesions. Another patient
of levofloxacin induced TEN was complicated with sepsis.
SJS patients did not leave any sequelae following discharge from
hospital. On the basis of Naranjo algorithm SJS patients were
classified as: 2 as possible; 5 as probable; and 2 as definite and
TEN patients were classified as 1 as possible 2 as probable and 3
as definite.
A detailed overview of the SJS/TEN patients in the form of age,
sex, drug therapy, and dose, indicator of use, onset of reaction,
concomitant drug therapy and cutaneous manifestations is shown
in [Table/Fig-2].

Discussion
The results in [Table/Fig-2] suggest that in a series of cases short
term use of AEDs act as a culprit in 56% of SJS/TEN patients
followed by NSAIDs use. The study revealed a mean age of 37
years in SJS/TEN patients. Aromatic anticonvulsants, lamotrigine,
NSAIDs, sulfasalazine and quinolones are among the high risk
medications most frequently associated with SJS/TEN [5,11,18,19].
Lamotrigine a phenyltriazine is a new anticonvulsant and has shown
its efficacy for prophylaxis of depression in bipolar disorders.
Our study reveals 2 cases of SJS and 2 cases of TEN which are
associated with LTG use and reaction occurs within 3 weeks after
the initiation of therapy. This is in conformity with other studies where
LTG has strong association with SJS/TEN. In two cases of our
study valproate is a concomitant drug with LTG. Its concomitant use
with LTG significantly increases the risk for development of adverse
cutaneous reaction. [20]. Valproate increases plasma levels of LTG
by inhibiting its metabolism [21,22]. Moreover, there have been
several case reports on the short term use of LTG in association of
SJS and TEN [23-28].
Other drugs including aromatic AEDs show an onset of reaction
within 1-2 months. The results are obviously showing predilection
for female gender. Despite, no evidence based medicine standards
of acceptance; present study reveals that all the patients responded
well to short-term administration of systemic corticosteroids without
any mortality. In patients, where AED therapy were offending agents
the drugs were withdrawn immediately as a measure for prevention
of drug reaction and were switched to Levetiracetam and Clobazam
to maintain seizure free remission.
Since the uncertainty persists regarding the well defined treatment
modalities of SJS/TEN other treatment protocols besides system
corticosteroids are high dose immunoglobulins (IVIG) [29-31],
thalidomide [32], cyclosporine [33,34], TNF-antagonists [35],
plasmapheresis/plasma exchange [36] and cyclophosphamide
[37].
In view of the pharmacogenetic influences underlying great number
of drug reactions like HLA-B 1502 being associated with SJS/TEN
induced by CBZ, PHT, and LTG [38]. HLA-B 5801 with allopurinol
induced SCARs [39] and HLA-B 5701 with abacavir hypersensitivity
[40]. It is also suggested that ethnicity has a role to play in difference of
the individual genetic susceptibility [41]. A pharmacogenomic study
done on CBZ has shown a strong association of HLA-A-3101 and
CBZ- hypersensitivity in Caucasian patients [42]. This association
encompasses all forms of cutaneous eruptions besides SJS/TEN.
This is in contrary to association of HLA-B 1502 which is specific
for SJS/TEN in Chinese patients. The association with HLA-A 3101
and CBZ hypersensitivity has been replicated in Japanase [43],
South Korean [44] and Canadian populations [45].
More recently, drug labels of various drugs have been altered by
the US Food and Drug Administration (FDA) and by the European
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www.jcdr.net

S.No

Samina Farhat et al., Antecedent Drug Exposure and Management in SJS and TEN

Age/Sex

Drug Therapy

35/F

Lamotrigine (LTG)

Dose

12.5mg/day Initially
Followed by 25mg/day,
Then 50mg/day

Concomitant drugs

Cutaneous
manifestation

Indications

Days to onset

Seizures with
BPAD

20

Quetiapine SR 200mg
Sodium valproate (600mg/day)
Etizolam (1mg/day)
Propanolol (40mg/day)

SJS

BPAD

15

Metoprolol SR 100mg/day
Clonidipine 10mg/day
Olmesartan 20mg/day
Rosuvastatin 5mg/day
Quetiapine 25mg/day
Clopidogril 75mg/day Aspirin 75mg/
day

SJS

58/F

LTG

25mg/day for week

Then 50mg/day second week
Increased to 100mg/day

30/F

LTG

25mg/day,

BPAD with
depression

15

Paroxetine
Clonezepam 12.5mg/day

TEN

30/F

CBZ

200mg/day,

Trigeminal
Neuralgia

10

Naproxen -500mg/day

TEN

300mg/day

OLE
post traumatic
epilepsy

10

Gabapentin 400mg/day
Nortryptiline 10mg/day
Citicoline 500mg/day
Piracetam 400mg/day
Vit B complex

SJS

Ankylosing
spondylitis

15

Thiocholchicoside 8mg/day

SJS

60/M

PHT

26/M

NSAID

50/F

Levofloxacin

750mg/day

UTI

10

None

TEN

60/F

Piroxicam

40mg, i/m stat

LBA

None

SJS

27/F

Ibuprofen

1200mg/day
For 2-3days

Osteoarthritis

Paracetamol 1000mg/day

SJS

10

24/F

Levofloxacin

500mg/day i.v infusion

Followed by Levofloxacin 500mg/
day
Cefpodoxime 400mg/dayfor 5days

RTI

None

TEN

11

50/F

Piroxicam

40mg, i/m stat

LBA

None

SJS

12

35/F

Sulfasalazine
(delayed release
form)

Aceclofenac 100mg/day
Thiocholchicoside 4mg/day

SJS

13

54/F

LTG

Valproate 1200mg/day
Levothroxine 50mcg/day

TEN

14

20/F

CBZ

15

16

17/F

22/F

CBZ/PHT

PHT

NA

Rheumatoid
arthiritis

1
month

Initially 50mg/day increased within

week to 100mg/day

GTCS

28

Initially CBZ CR 400mg/day CBZ CR

600mg /day

GTCS

2 months

None

TEN

GTCS

2 months

None

TEN

1000mg/day for month

Initially PHT 250mg/day for 1 month

Then CBZ-SR 200mg/day for 3days
followed by CBZ SR 600mg/day then
PHT 200mg/day

PHT 300mg/day

Focal epilepsy

1 month

AKT-4
R-450/mg /day
Z-1500mg/day
E 800mg/day
H-300mg/day

SJS

[Table/Fig-2]: Characteristic of 16 cases of SJS/TEN with different drug therapies

LTG: Lamotrigine, BPAD: Bipolar affective disorder, CBZ: Carbamazepine, PHT: Phenytoin, OLE: Occipital lobe epilepsy NSAID: non steroidal anti-inflammatory drug, UTI:
urinary tract infection. RTI: respiratory tract infection, LBA: low back ache, FDE:fixed dose eruption. R: rifampin, Z: pyrazinamide, E: Ethmabutol, H:Isoniazid, CR: continous
release, NA: not available

Medicine agency (EMA), which requires testing for HLA prior to the
prescription of drug concerned.
Realizing the importance of these genetic susceptibilities it is highly
recommended that genotyping be undertaken as a screening
measure for these HLA-B alleles in North Indian ethnic population
prior to prescription of these respective drugs.

CONCLUSION
The present study illustrates that inspite of rare occurrence of
SJS/TEN North Indian ethnic population has great predisposition
of SCARs due to aromatic AEDs, LTG, oxicam NSAIDs and
quinolones. These reactions need to be reported at an earliest as
it has an instrumental role and forms an important component of
pharmacovigilance programmes. Patients should be educated
to avoid re-exposure to suspect drug (s) to yield outcome based
results.
Journal of Clinical and Diagnostic Research. 2016 Jan, Vol-10(1): FC01-FC04

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PARTICULARS OF CONTRIBUTORS:
1.
2.
3.

Associate Professor and Head, Department of Pharmacology, Government Medical College (GMC), Srinagar, India.
Lecturer, Department of Pharmacology, Government Medical College (GMC), Srinagar, India.
Professor and Head, Department of Dermatology, Government Medical College (GMC), Srinagar, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Muddasir Banday,
Lecturer, Department of Pharmacology, Government Medical College, Srinagar-190001, India.
E-mail : [email protected]
Financial OR OTHER COMPETING INTERESTS: None.

Date of Submission: Aug 22, 2015

Date of Peer Review: Sep 27, 2015
Date of Acceptance: Nov 05, 2015
Date of Publishing: Jan 01, 2016

Journal of Clinical and Diagnostic Research. 2016 Jan, Vol-10(1): FC01-FC04